2023_03_10_COI_CL_AL_UL_PL_WC_SAM.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

Phoenix, AZ 85007 2nd Fl, NW, Mail Drop 53C1 1789 W. Jefferson St.

Department of Economic Security The State of Arizona

To the fullest extent permitted by law, Contractor shall defend, indemnify, and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as “Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as “Claims”) for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any claim or amount arising out of, or recovered under, the Workers’ Compensation Law or arising out of the failure of such Contractor to conform to any federal, state, or local law, statute, ordinance, rule, regulation, or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for primary loss investigation, defense, and judgment costs where this indemnification is applicable. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents, and employees for losses arising from the work performed by the Contractor for the State of Arizona. For a schedule of services please see attached memo.

3,000,000Aggregate Limit 1,000,000Occurence Limit

4/18/20234/18/2022PHUB811195

Professional Liability

Sexual/Physical Abuse or MolestationA

1,000,000 1,000,000

4/18/20234/18/2022PHUB811195A

1,000,000

4/18/20234/18/2022PHPK2403789YYA

3,000,000 3,000,000 1,000,000

5,000 100,000

1,000,000

4/18/20234/18/2022PHPK2403789YYA

Philadelphia Indemnity Co.

85206Mesa, AZ 85206 444 S. Greenfield Rd.

Odyssey Services Corporation Pillar Health Group Two Holdings, Inc.

brittany@pinnacleinsuranceco.com (480)538-5027(480)585-9770

Scottsdale, AZ 85260 16420 N. 92nd St, Suite E226

PINNACLE INSURANCE CONSULTANTS

8/4/2022

TO: FROM:

FAX:

Date: 8/4/2022

Mesa, AZ 85206

Contract #05802

Services Include: Habilitation/Support Hourly, Group Supportive Employment, Transportation, Employment Related Habilitation, Individually Designed Arf, Respite Attendnt Care, Individual Supportive Employment, Employment Support Aid, Treatment & Training (DTA) and TTE.

Abusive Conduct Liability is included.

Professional Liability is included in the Umbrella. Total Professional Liability Limits $2,000,000 each claim/$4,000,000 aggregate.

Blanket Contractual Liability both written and oral are included under the General Liability (CGL) coverage.

Fire Legal Liability $100,000 is shown on the certificate as Damage to Rented Premises $100,000.

Odyssey Services Corporation 444 S. Greenfield Rd.

Pillar Health Group Two Holdings, Inc.

(480)585-9770 (480)538-5027

Scottsdale, AZ 85260

PINNACLE INSURANCE CONSULTANTS

16420 N. 92nd St, Suite E226

CTR058022 : SMALL BUSINESS CONSULTATION

CTR044676 : TUTORING

CTR056119-2 : Pre-Employment Transition Services

POLICY CHANGE DOCUMENT

POLICY NO.:

CHANGE EFFECTIVE CHANGE # REVISION #

DESCRIPTION

PHPK2403789

207/28/2022

08/03/2022____________________ Issue Date

Added:

Manuscript Endorsement-Additional Insured-State of Arizona

As per attached

Philadelphia Indemnity Insurance Company

NAMED INSURED

25827 Pinnacle Insurance Consultants

Pillar Health Group Two Holdings, Inc.

dba Odyssey Services Corporation

MAILING ADDRESS 444 S Greenfield Rd Mesa, AZ 85206-2010

POLICY PERIOD: FROM TO at 12:01 A.M. Standard Time at your mailing address shown above.

Path ID 15837663

0.00

NO CHANGE

COUNTERSIGNED BY

(Date) (Authorized Representative)

04/18/2022 04/18/2023

In consideration of the premium reflected, the policy is amended as indicated below:

Total Annual 0.00Additional/Return Premium $ Additional/Return Premium $

Total Prorate

NO CHANGE

Insurance Policy

PI-MANU-1 (01/00)

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY

All other terms and conditions of this Policy remain unchanged.

To the fullest extent permitted by law, Contractor shall defend, indemnify, and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as "Indemnitee") from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys' fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as "Claims") for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any claim or amount arising out of, or recovered under, the Workers' Compensation Law or arising out of the failure of such

Contractor to conform to any federal, state, or local law, statute, ordinance, rule, regulation, or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for

Claims arising solely from the negligent or willful acts or omissions of the

Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for primary loss investigation, defense, and judgment costs where this indemnification is applicable. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents, and employees for losses arising from the work performed by the Contractor for the State of Arizona.

Additional Insured-State of Arizona

State of Arizona Certificate CGL AND AL.pdf